The session addressed the various manners in which gender and social inequalities may negatively impact on population health and general wellbeing. It further looked at ways in which women can be empowered to allow them to develop a holistic approach to their specific health and other related needs. Examples showed that implementing gender-based analysis can produce profound changes in the treatment of women's specific problems.

Mr. K. Narendar, Chief Executive of the Development of Humane Action Foundation (DHAN), Madurai, India, presented the activities of his organization, which promotes improved health outcomes through microfinance intervention. To put his foundation's work into perspective, Mr. Narendar first reminded the audience that population health is strongly correlated with poverty. Microfinance programmes have emerged as one of the significant mechanisms to address the deep-rooted causes of poverty. There is a growing body of evidence showing that access to microfinance services is positively correlated with factors that have a positive impact on health, such as nutritional intake or contraceptive usage, he said.

The microfinance programme of the DHAN, through savings, credit and insurance, is aimed at developing appropriate savings that can be devoted to health care. Specifically targeted at women, it enables poor women to increase expenditure on the well-being of themselves and their children, which ultimately affects the health outcome at the family level. Mr. Narendar cautioned that such schemes are not appropriate to address higher health care needs, for which social security measures such as health insurance must be in place.

Mrs. Berhane Ras-Work, from the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) addressed the problem of female genital mutilation (FGM) in Africa. FGM is a widespread problem on the continent, affecting at least 28 countries. It is rooted in and nurtured by tradition, culture, religion, far-reaching misconceptions and socio-economic circumstances. All members of the community are participants in the continuation of this most brutal form of violence and governments tend to be silent, thereby justifying this violation of Human Rights, she said.

NGOs have played a key role in giving international recognition to gender inequality and violence. The IAC has initiated action and shown that it is possible to impact positive changes of attitude through the empowerment of women along two lines. First, by offering them micro-credits aimed at curbing their economic vulnerability. Indeed, women accept gender-based violence to ensure the security of their marriage and the survival it provides. Second, by giving them education and information to erase the misconceptions perpetuating the practice of FGM and to develop women's valuation of their bodies and health. In parallel, the IAC has embarked on a micro-credit scheme with excisers themselves, to help their conversion to other income-generating activities. Such schemes have already been successful in persuading excisers to stop their traditional practices.

Mrs. Berhane noted finally that such strategies should be further developed but that their success depended on accompanying, additional measures starting with strong political commitment and investment.

Mr. Manuel Carballo, from the International Centre for Migration and Health, Vernier, Switzerland, focused on the problems faced by migrants, an ever growing population worldwide. The migrant population was officially 195 million in 1995, but certainly amounted to three times that number when illegal migrants were taken into account. The health problems of migrants are a complex issue, combining pre-migration health profiles, diseases and health problems acquired during transit and newer ones acquired in the host country. Hence, care should be specifically tailored to the migrants' health profiles, a course which is undermined in times of increased socio-political resistance to migrants.

The nature of their health problems is only one element in all those undermining migrants' health, Mr. Carballo said. Access to health care for migrants is dependent on the availability of specific services adapted to their different psychosocial, cultural and linguistic backgrounds. The availability of such existing services should be known to the migrants, but this has been shown not to be the case in almost half of those migrants surveyed in Geneva. Such services should also be legally available, for example through a scheme of health insurance, and they should be affordable, taking into consideration the overall low income of migrants.

As migration continues to increase, Mr. Carballo concluded, medical insurance coverage which includes migrants, specific training of health personnel to handle multicultural differences and outreach to the migrant population for health promotion and disease prevention is more critical than ever.

Mrs. Zully Moreno Chacon, from the Hospital of Costa Rica in San José came with a concrete example of how gender-based analysis helped the transformation of the Women's hospital in Costa Rica from a traditional one to one working with women themselves to design tailor-made strategies addressing specific needs. The transformation was a far-reaching process involving strategic planning; revision of physical infrastructure, working processes and administration; space distribution; challenge of management structures; allocation of budgets; new practices and methodologies.

The key to the success of this initiative was to empower women in the process and to develop a holistic approach to their specific health and other related needs. Active participation was fostered by the creation of associations and a health network. Employees' training was carried out to improve the sensitivity of care for women.

Mrs. Moreno noted that implementing gender-based analysis produced profound changes in the treatment of women's specific problems and that female patients demonstrated a real appreciation of the new approaches and resources that were developed.

Session Report

The final plenary session of the "Geneva Forum: Towards Global Access to Health" was dedicated to summarizing the key issues which emerged during the three days of discussion and exchange and to formulate suggestions on how to develop these issues in the future. The final plenary was also a moment to thank all the contributors of the Forum for their effort and participation.

The first speaker, Dr. Hassan Mshinda, Head of the Ifakara Health Research & Development Centre in Tanzania, stressed that previous health initiatives have concentrated on aspects such as equity, participation, and multi-sector and comprehensive healthcare. However, Dr. Mshinda urged that as an increasing number of actors are becoming involved, and a greater pressure is put on immediate results.

According to Dr. Mshinda, there is a clear need for an agenda in order to achieve sustainable development of health. The Paris Declaration on Aid Effectiveness set out the principles for doing a better job in delivering and managing aid. Global Health Initiatives have their merits, but it remains indispensable that countries strengthen their national health systems, because this is the key to improving access to health care, said Dr. Mshinda. In any case, such initiatives will eventually have to be absorbed by governments' health systems.

National governments have a key role to play and it is their responsibility to have a long term strategy for sustainable development of health care systems. Long term commitments from partners, as well as monitoring and audit tools could certainly enhance this process. Dr. Mshinda said that the challenge of Global Health Initiatives is to realize their integration at the global, national and regional levels. To create the necessary interaction between those different levels, there is a need to establish even more contractual partnerships.

Dr. David Heymann, Executive Director, Communicable Diseases, of the World Health Organization (WHO), spoke about the role of partnerships in promoting health security, emphasizing the global character of health problems and, more specifically, the security issues related to infectious diseases. He said that while new infectious diseases are appearing, more worrying is that infections such as cholera and yellow fever, which were thought to have been eradicated, are re-emerging. Analysis shows that increased international travel has stimulated the worldwide spread of some diseases, such as SARS and malaria. While malaria is not contagious, it does get transported through mosquitoes to areas where it normally does not occur. As a result, these diseases occur far from their original source.

The spread of numerous infectious diseases is closely linked to animals and insects. The movement of animals to market is a key factor in spreading infectious diseases to other locations, especially when cattle is not vaccinated. Other diseases can be transmitted through international trade in agricultural products as in the case of Creutzfeltd-Jacob disease. Dr. Heymann reminded the audience that there is always a risk of existing viruses mutating and creating new pandemics.

Will non-immunized humans serve as an intermediate host in the transmission of diseases? The framework for International Health Regulations has been improved and updated on an ongoing basis since 1947, said Dr. Heymann. The WHO receives inputs from 110 different networks around the world, whose task it is to collect data and to continuously monitor the development of diseases in their region. The WHO reacts to information gathered through the Global Outbreak Alert and Response Network (GOARN).

Distribution of information and education related to infectious diseases still rests on weak ground in developing countries, claimed Dr. Heymann. In this context, it is not surprising that the three diseases with the highest death toll, TB, malaria and HIV/AIDS continue their expansion in sub-Saharan countries. He highlighted the staggering negative economic impact of those diseases by giving one example: GDP in sub-Saharan Africa would have been 100 billion USD higher in 2000 if malaria had been eradicated 35 years ago.

Only systematic partnerships between developed and developing countries will enable significant changes to present trends, stated Dr. Heymann. Those partnerships should focus on four areas: research and development, access to vaccines, prevention, and monitoring. The WHO clearly places health at the centre of development, because it is essential for sustainable economic growth. Although the WHO has a role to play and global partnerships have been expanding, the rolling back of infectious diseases is primarily a matter of high level political commitment in developing countries themselves. The declines in HIV/AIDS in Uganda and of TB in Peru are examples of such commitment.

Ms. Ruth Dreifuss, former President of Switzerland, drew attention to the underlying political issues of the topics discussed during this Forum. These include the interdependence between the North and the South, the search for new medicines, the outcome of the World Trade Organization (WTO) summit at Doha, pandemics, and so on. In this context, she underscored the important role of NGOs in raising public awareness and the necessity of forming partnerships between the public and private sectors, while it should remain the responsibility of governments to provide the engine for the process.

Ms. Dreifuss further stressed the importance of the recommendations and conclusions of the Commission on Intellectual Property Rights, Innovation and Public Health, which she had chaired at the World Health Assembly (WHA) and the report of which has recently been completed. Three concepts surfaced in connection with vaccines and medicines in general: availability, acceptability and accessibility. The commission's major conclusions were that present efforts are not sufficient to assure the continuity of existing programmes; the generosity of the private sector should not be a substitute for the public sector spending; and a global action plan is essential for meeting the public's health needs. In order to stop the current stagnation, the speaker proposed four levels of intervention. First, structuring health care to avoid competition between private and public sectors. Secondly, training health workers and seeking to prevent their exodus to rich countries. Thirdly, focusing on vulnerable and marginalized groups such as children and women. And finally, to seek innovation in the pharmaceutical sector and promote the use of generic drugs.

The next speaker, Mr. Alok N. Mukhopadhyay, C.E.O. of the Voluntary Health Association of India, stressed the interdependence of economy and public health. "Health is not an expense but an investment for governments", he continued. All people want to live healthily and have a basic right to claim the conditions to create and maintain their health. A vital question for the speaker was whether health had to be offered as a commodity in the marketplace. He pointed out that more spirituality was needed. In this context, Mr. Mukhopadhyay quoted Mahatma Gandhi's view that "the world has enough for everyone's needs but not for everyone's greed". He concluded by stressing the lack of dialogue between the different medical and health care systems and the difficulties in attracting workers and experts to public health care.

The final speaker, Professor Bruno Grijseels from the Prince Leopold Institute of Tropical Medicine in Antwerp, highlighted the role and responsibility of academic institutions. Academics and scientists could learn from taking a holistic approach to global health problems instead of focusing on isolated research problems. Access to quality healthcare is a real challenge which can only be won by establishing partnerships, he said. Scientists have the responsibility not to lose sight of reality and to develop systems which can be implemented for the benefit of the public.

In her closing remarks, Professor Le Coultre, Membre of the Forum Organizing Committee and Vice-Dean of the Faculty of Medecine of the University of Geneva, commended the quality of interaction and idea-sharing at the Geneva Forum. She mentioned that this Forum had been a starting point, called for feedback from the participants and promised additional efforts to bring more people from the developing world to the next Global Health Forum.

Dr. Louis Loutan, President of the Forum Organizing Committee and the Geneva University Hospitals, thanked the organizing team, the advisory board, the Forum participants, the sponsors and the volunteers --there were over 60 involved in the conference-- for their contribution to this first edition of the event. He closed the Forum by inviting participants to use the conference web site's feedback form to share their impressions in view of a next edition of the event.

Session Documents

Session Report

Plenary V addressed the current challenges and conditions for effective capacity building in the health workforce as well as medical research to improve health and give access to health care in developing countries.

Dr. Manuel Dayrit, of Human Resources for Health at World Health Organization (WHO), discussed the current challenges and conditions for effective capacity building in the health workforce. Although Mr. Dayrit's focus was on human resources for health, he insisted throughout his presentation on the fact that capacity building was constantly taking place in a much broader context of socioeconomic and political circumstances, institutions, and involved many actors from different horizons. Hence, it is essential, in order to be effective, that capacity building be systemic. However, failure to address the capacity constraints (political, institutional) limiting the achievement of overall capacity building project objectives has repeatedly been shown.

Mr. Dayrit defined "capacity building" as "a process by which individuals, groups, institutions, organizations and societies enhance their abilities to identify and meet development challenges in a sustainable manner." As set forth by WHO's late Director General, Dr. Lee Jong-wook, the ultimate goal of capacity building is "to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere."

The health workforce, Mr. Dayrit noted, must be understood as "all people engaged in actions whose primary intent is to enhance health," not only doctors and nurses, but also such diverse professionals as economists, drivers, cooks, etc.

Mr. Dayrit, provided various illustrations of the strong positive correlation observed worldwide between the proportion of health workers in the population and population's health measured by various indicators. The latest WHO World Health Report (2006) provides ample evidence supporting the view that shortages of health workers in certain areas in the world must be addressed as one key step to improve overall health. The causes of such shortages are many and diverse and may be grouped into three tiers: the entry level, including planning, education and retirement; the workforce level, including supervision, adequate compensation, continuing education; and the exit level, limiting emigration, changes in career and ensuring the health of the workforce. Only a strategy tackling these three aspects (a "lifespan strategy") may lead to effective sustainable results. To illustrate this point, Mr. Dayrit described the case of Thailand where multiple strategies have helped to improve the retention of trained health workers in rural areas. With concerted regulatory, economic, educational, managerial and social strategies, the country has indeed managed to shift the ratio of health workers in Bangkok v. those in the northeast of the country from a 22:1 ratio in the eighties to a 10:1 ratio in 1999.

In conclusion, Mr. Dayrit reiterated the view that capacity building efforts will succeed only where they take adequate account of the prevailing local politics, economics and institutions and are country-owned rather than donor-driven. To that effect, he noted that countries have to take the lead in developing capacity building efforts and that donors should harmonize their support around the countries' priorities.

Ms. Odette Morin, Director of Regulatory and Scientific Affairs of the International Federation of Pharmaceutical Manufacturers and Association (IFPMA), presented the newly created IFPMA Clinical Trials Portal, launched in 2005, that is the first portal to provide public, online information about on-going and completed clinical trials sponsored by pharmaceutical companies worldwide.

The portal was developed as a response to various pressures for improved trial transparency. Through their associations, the pharmaceutical companies have taken a joint position on the disclosure of clinical trial information that has led to the creation of the portal. Pursuant to ongoing public pressures, the number of clinical trial postings on the portal has almost doubled during the first months of its launch.

The portal is not a database but is structured as a platform giving access to various sources which centralize information, such as national industry associations, governments or international organizations. It allows multiple-criteria searches in English, French, German, Japanese and Spanish.

The portal is not only useful to doctors and patients, it is also an essential tool, as was discussed after Ms. Morin presentation, to inform health systems management. Of course, the portal may be only as good as the information made available by companies and governments. It was hence emphasized that national registries should be improved in many regions to improve coverage.

Mr. Stephen A. Matlin, Executive Director, Global Forum for Health Research, discussed the crucial role of health research in ensuring that people everywhere have access to health. Mr. Matlin first provided an overview of the changing face of health problems worldwide. Although infectious, communicable diseases (CDs) remain the major health burden in Africa, there is an overall increase in non-communicable diseases (NCDs) among low and medium income countries (LMICs). Health research agenda should adapt to these evolving needs.

Health research, Mr. Matlin highlighted, is not limited to biomedical research and the development of new products. The health research agenda should also focus on systemic aspects such as strengthening health policy and systems, the promotion of health equity, the study of social and other determinants of health including the availability of public transport networks for access to health resources.

It is widely recognized that there is a major lack of spending on health research for the needs of developing countries, both by HICs and by LMICs themselves. Although global health research expenditure is growing at a rapid pace, only a small proportion of it (less than 5% in the 1990s) is devoted to diseases and health problems that are endemic in LMICs. As a result, during the last few decades, very few new products for diseases that are mainly endemic in poor countries were registered for clinical use. In parallel, health systems and health research capacities in LMICs have not been sufficiently developed.

In order to tackle the disease burden in LMICs, concerted approaches should be implemented by both LMICs and HICs. HICs should focus on research that generates leads for LMICs and support country-based research and capacity building in LMICs. LMICs should similarly support their own research capacity and utilization. They should focus on the development of national health research systems, foster innovation and ensure that local research capacity addresses local priority health needs.

There is an emergence of innovating developing countries, such as Brazil, China, India and South Africa. These countries have demonstrated a growing capacity to undertake health innovation and assume an increasing role in the development of new drugs, vaccines and diagnostic tools, as well as of new techniques and new policies in health systems and services. One characteristic of these countries is that they manage to span the spectrum from innovative research to product delivery.

One major source of funding for, in, and by, LMICs is philanthropy. Over the 1993-2003 period, the 50 most generous philanthropists collectively donated over 50 billion USD. Public-Private Partnerships (PPPs) are playing a growing role in the financing of health research for LMICs. PPPs' Research & Development (R&D) expenditure has increased dramatically since 2000 and 75% of all neglected disease R&D projects are currently conducted by PPPs. The public sector should devote an increased share of available R&D resources to the health needs of developing countries, as they have fallen short of meeting the the targets set at the 1990 Commission on Health Research for Development (2% of government health budget on essential health research).

Mr. Matlin concluded by highlighting areas to which government financing of health research for development should focus. In HICs, greater priority should be given to national research programs and more health research should be included in bilateral and multilateral channels. In LMICs, in additional to giving greater priority to national health programs, capacity building for national health research systems and innovation should be emphasized.

1Director General, Indian Council of Medical Research, New Delhi, India

Key issues:

Impressive strides have been made in biomedicine and it is on account of the results of health research that the people enjoy a longer life expectancy through use of products of research like the vaccines, drugs, diagnostics, better management of diseases and life threatening conditions. However, benefits of health research are not available to those countries, communities and individuals that need it most.

Meeting challenges:

In India, the burden of ill-health is higher among the poor. The infant mortality rate is two and half times higher and the under-five mortality rate is three times higher in the lowest quintile of the population as compared to the highest. The total fertility rate in the highest quintile is almost half that of the lowest quintile of the population. Although the burden of disease is high among the poorest quintile, their access to health services is limited. The poorest 20% of the population get only 10% of the public subsidies for curative care. There is an urgent need, therefore, to identify approaches and means to translate knowledge to effective interventions to improve access to health care and services. This means better utilization of existing tools, development of new tools for diagnosis, treatment and prevention of diseases as well as working out strategies that would result in their reaching the population in greatest need.

Conclusion (max 400 words):

The research activities of the Indian Council of Medical Research (ICMR), the apex body for biomedical research in the country are aimed at reduction of poverty through income-generating schemes, catalysing community participation in disease control programmes, developing innovative strategies that generate income, decreasing the man-days lost due to illness and loss of wages by developing more effective treatment and of shorter duration. Studies aimed at promoting gender equality and empowering women for contraceptive choices have led to the development and introduction of newer contraceptives including emergency contraception and safe abortion methods in the country. To improve child survival, studies on home-based newborn care interventions, estimating the disease burden for vaccine-preventable diseases and evaluating alternative modes of delivery of existing vaccines have led to some effective management strategies. Studies for improving maternal health have led to the development of feasible and cost-effective methods and management strategies to prevent and treat maternal morbidities. Research in nutrition has led to the formulation and implementation of national nutrition programmes, use of iodized salt and availability of fortified foods in the country. Development of diagnostic kits and effective treatment regimens for infections such as HIV/AIDS, malaria, TB and others diseases like Leishmaniasis have been given additional emphasis. Studies to understand the disease burden, epidemiology, risk factors and also genetic disorders like heamoglobinopathies have provided inputs for development and implementation of national health programmes and integrated disease surveillance in the country. Research in diabetes has facilitated preventive measures and improved management strategies. Mapping of diseases like cancer has helped in formulating strategies for prevention and management. For ensuring environmental sustainability, studies on impact of air pollution, occupational exposures, monitoring pesticides in environment and food and developing bio-markers for detection of environmental toxins have been carried out. Pre-clinical and clinical testing of newer molecules developed by Indian pharmaceutical companies has led to production of newer drugs for disease management. The clinical trial registry at ICMR will further help in evidence-based interventions and implementation of best practices in the country.

Session Report

The fifth largest nation in the world does not have sufficient access to health. Indeed if migrants were seen as a country, they would represent a significant nation in terms of population. How can we explain that so many people do not have access to health care? The focus of this symposium, chaired by Anita Davies from the International Organization of Migration (IOM) and Sandro Cattacin from the University of Geneva, was on the unequal provision of health services for migrants.

Inequalities are caused by problems that we can classify on three different levels:

At the patient level: language, culture and social circumstances can inhibit access.

At the provider level: the inability to communicate with patients makes physicians reluctant to deal with foreign patients.

At the level of the care delivery system: legal restrictions and administrative complexities make it difficult to provide effective service for migrants.

These inequalities are also worsened by adopting a national view. Brian Gushulak, a migrant health specialist, emphasized the importance of a global perspective when dealing with the issue of access to health for migrants. According to this speaker, a national view of the problem at hand would limit the solutions and prevent them from being linked to development, economic and security matters. Indeed, all the participants agreed that migration was part of globalization and that it should be treated from a global point of view. "There are no local diseases and therefore there are no local solutions" Patricia Walker from the Department of Internal Medicine of the University of Minnesota, in the USA, pointed out.

One must not look upon the immigrant community as a homogenous group; its members have different social and cultural backgrounds. In order for the care delivery system to be effective, it has to be culturally competent and knowledgeable about both ethnic and social differences. This is illustrated by the fact that most patients from this community do not dare consult a physician due to language barriers and in turn 78% of the doctors do not like taking care of immigrants due to the complexity of the process.

However, the unequal access to health care was not the only point that was discussed. It was pointed out that providing better health services for migrants is in fact beneficial for host countries. We particularly have to focus on fast intervention because, not only does it prevent diseases like Tuberculosis from spreading, but also reduces the cost of treatments. Indeed, the further the illness is developed, the more complex and expensive it becomes for both patients and health care providers. Focusing on illegal immigrants, Dr. Francesco Castelli from the Infectious and Tropical Diseases Unit of the University of Brescia in Italy, pointed out that more than 70% of HIV infected people are unaware of their condition.

Thus, in order to ensure access to health for migrants, it is important to insist that health should be regarded as a human right and that all citizens, migrants or natives should be entitled to it.

During the 1970s, the labour needs of European States favoured intensive legal migration to sustain growing economic growth. Afterwards, economic recession in Europe caused higher unemployment rates and legal migration into Europe has become increasingly difficult, resulting in a growing number of undocumented migrants from Southern and Eastern countries into Europe.

Meeting challenges:

Host European countries are usually reluctant to promote health care programmes for undocumented migrants, fearing to give incentive to further migration flows, yet forgetting the basic human right of every person to access health regardless of his/her legal status. Furthermore, discrimination and internal inequalities in health care for marginalized minorities often have an impact also on the economic, social and health status of the host population, possibly generating public health problems. Some European countries have set up legal systems to offer illegal migrants the right to health care, but wide variations exist among the different countries as to the quality and quantity of access to care according to legal status. Furthermore, even a significant proportion of legal migrants may not have access to health care because of their ignorance of basic rights.

Conclusion (max 400 words):

It is our hope that the European and international bodies, including the newly created United Nations Human Rights Council, may soon address the increasingly important issue of guaranteeing every human being the right to access care.

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Session Report

Image: courtesy of The Public Health Image Library (PHIL) http://phil.cdc.gov/Phil/

Populations of modern Europe live in different national socio-economic settings, making the study, evaluation and comparison of their respective healthcare systems a complex exercise. Correspondingly, health inequalities within this vast region are also intricate and multiple. The three speakers provided interesting insights on the different determinants of these inequalities, mainly focusing on the roles played by the public and private sectors, whilst revealing the often misconceived correlation between the inequality in access to healthcare and the private and/or public delivery of healthcare services.

Dr. Willy Palm, Dissemination Development Officer of the European Observatory on Health Systems and Policies in Brussels, Belgium, argued that while soaring health care costs is a draw for private sector involvement, it is unclear what private sector involvement in healthcare entails. Advocates for privatization of healthcare services favour the potential for increased efficiency, choice, service, and quality of care. Opposing groups, however, believe that privatization will undermine the solidarity principle, whereby the rich and healthy subsidize the care of the poor and sick. Dr. Palm's slides showed a private-public continuum, in which various 'hybrid' health systems are revealed. His graphs demonstrated that all European countries have a mixed stream of funding to pay for health care, including taxes, social security, user charges, and private insurance. On average, governments funding covers 75% of all health care costs. Dr. Palm stressed that governments considering change should first identify their goals for health care, followed by an assessment of the benefits and tradeoffs of introducing private actors into a public system. Results of such assessments may sometimes be contrary to expectations. For example, improved efficiency in privately run primary care facilities in Estonia increased the number of people receiving care, and therefore led to increased spending. In the Netherlands, the principles of competition and solidarity are combined in its health system reforms. He concluded that governments should act as careful stewards of health systems, providing clear regulations for all involved public and private actors.

Sir William Wells, Chairman of the NHS Appointment Commission, gave a documented overview of the British Public National Healthcare System (NHS), discussing the problems it now faces and the solutions which have been implemented. A well established system of 60 years and a widely used "role model" in many countries, the NHS is nevertheless, according to William Wells, "in need of rejuvenation". Living in a general misconception about its initial objectives (a system that was meant to provide healthcare to all who need it but it was not designated to provide ALL healthcare services), the NHS will have to quickly tackle its low productivity. Measured in terms of number of patients treated per doctors, the 4% rise in productivity is astonishingly low compared to the increased amount of taxpayers' money received by the NHS (30 billion £ in 1997, 70 billion £ in 2006, and 90 billion £ in 2008). For the system to be "fit for purpose", it will require a reorientation of staff towards a more patient/customer friendly attitude, increased competition and smaller management groupings. Thus, by introducing contracts for private healthcare providers, which started in 2003, NHS is progressively opening to the private sector and encouraging competition. This phenomenon is uprooting the traditional staff culture and clearly pointing the way forward for the entire system. William Wells emphasized both the importance of these reforms and the fact that the system would not be entirely changed; after a major national debate it was decided that taxpayers should continue paying for healthcare service but that in return, the increase in taxes meant the NHS should provide the patient/customer "value for money". The controversial and "revolutionary" approach of allowing the private sector into NHS is part of a new trend in creating hybrid health systems.

Dr. Bakhuti Shengelia, Regional Adviser for Health Policy and Equity, Division of Country Health Systems at the WHO, examined the health systems of Central and Eastern Europe, where the former Soviet Republics have seen a five to eight year decrease in average life expectancy since the collapse of the Soviet Union in the early 90's. An estimated 3.2 million deaths, concentrated among men aged 20 to 60, would not have occurred in these countries had the health systems not suffered in the wake of political collapse. Since 1995, the rate of HIV infections has also increased at an alarming rate, making this one of the fastest growing AIDS epidemic region in the world. While public health has taken a setback in the Central and Eastern European societies, the poor are the most affected. Even though governments often promise a public health care system to meet the populations' needs, in reality they fail to provide these services, allowing for the growth of a de facto private system of informal payments. Other increased health risks among the uneducated and the poor such as higher incidence of smoking and heavy drinking also adds to the burden on existing health care systems. The dramatic disparity in access to health care is ironic, given the level of solidarity that once existed in these countries' health systems. In Georgia and Azerbaijan, for example, out of pocket payments by patients cover approximately 90% of all health care costs. To ameliorate the inequalities of the system, out of pocket payments by patients need to be drastically reduced and funding redistributed to target vulnerable groups. Aid from the European Union could be instrumental in achieving these goals.

All three speakers seemed to agree that the public vs. private debate is no longer relevant because the definitions of these terms have blurred considerably. The most effective health systems should well utilize both public and private actors. As one forum participant well pointed out, we should focus on the functionality of the system in reaching performance benchmarks, rather than the type of system.

With its 870 million people living in fifty-two countries, the WHO European Region is one of the most diverse. While health status has been improving steadily in the western part of Europe, in Central and Eastern Europe (CEE) it has stagnated and even deteriorated, particularly in the Former Soviet Union in the early 1990s. Economic collapse in many parts of CEE and lack of good governance dealt a heavy blow to health systems leading to deterioration of overall health and emergence of vast socio-economic inequalities. The social inequalities in health are much greater in CEE. Higher prevalence of poverty and social vulnerability and weak capacities of health systems to provide adequate coverage to the population limit the access to health care services for the poor and socially vulnerable groups, resulting in high burden of diseases among them. Low government spending on health in comparison to private spending, high shares of out-of-pocket payments, and insufficient risk protection put a lot of people with limited income at a high risk of catastrophic health care costs and impoverishment. Weak capacities of the Ministries of Health to exercise effective stewardship and coordinate intersectoral actions leave a lot of unexploited potential to reduce negative impacts and augment positive influences of wider socio-economic determinants on health and health inequalities.

Meeting challenges:

In order to address these challenges the countries of CEE need to employ a number of policy options in combination: (1) To ensure higher priority to health systems and increase the level of public funding of the sector. This requires strong advocacy from the MoH side and convincing of the highest level decision makers that investment in health contributes to overall economic development and welfare of the society. (2) To improve financial access to health services for the population, by guaranteeing an appropriate benefit package and introducing health care finance mechanisms that are based on the principle of solidarity subsidization of the poor and sick by the rich and healthy. (3) To provide social safety and reduce social exclusion for migrants, ethnic minorities, and other marginalized groups. (4) To reduce the resource wastage, which compromises the ability of the health system to attract greater investments and produce equitable outcomes for the whole society. The efficiency has to be achieved not at the expense of equity but for the sake of equity. (5) To strengthen quality and the range of services at the primary care level and ensure population access to them. (6) To scale up targeted health promotion and provide greater opportunities for the socially disadvantaged to practise a healthy lifestyle. (6) And most importantly, to strengthen the stewardship role of government to protect health and equity from unintended impact of other sectoral policies, mobilize and coordinate intersectoral efforts to tackle the health issues, and act on their wider social determinants.

Conclusion (max 400 words):

Reducing social inequities in health is a difficult goal to be achieved only by the health sector. It requires commitment and involvement of the governments at various levels and across sectors. Collaboration with the private sector is also extremely important. The Western European countries as members of the EU have a great responsibility in helping the countries of CEE to overcome these challenges. This could involve financial, technical and political support. Structural adjustment funds allocated to the new EU member states could provide significant financial input to building stronger health systems if properly invested. Technical support and transfer of know-how should focus on those areas that could have the highest impact on reducing social inequalities in health. Political support could empower the stewards of the health system to be more effective advocates and champions for intersectoral actions for health and equity.

Session Report

To achieve global access to health care requires the participation of a range of actors including patients, well-organized NGOs and governments that are held accountable. This specific symposium covered a range of issues that are critical to providing access to health for all, including civil and social issues and the role, vision and improvements provided by the People's Health Movement (PHM) and the Global Health Watch (GHW).

Mrs. Harkness explained the role of the IAPO, which is to ensure that the voice of patients is heard when health policies are defined. Their mission is to ensure that the patient remains the focus in health care, rather than focusing on technology, hospitals, health care personnel or diseases. Currently the focus is on diseases, whereas the real focus should be on patients since only they can communicate what they require. Information is critical and must circulate. Surveys show that the main concerns (access to timely treatments, strong relationships between patients and care givers and perceptions of health care amongst patients and patient's organizations) are the same regardless of the region where the patient comes from.

Subsequently, Mr. Hani Serag of the People's Health Movement (PHM) presented his organization, including its role and the challenges it faces. According to PHM, the drug stakeholders and pharmaceutical companies have no real interest in achieving health for all. A growing disparity between the rich and the poor and between the more developed and less developed countries can be clearly observed. The PHM claims that, in order to give advantages to pharmaceutical companies, western governments and the World Health Organization (WHO) are constantly putting pressure on poorer countries to adopt legislation that restricts access to drugs, while being beneficial to drug companies. According to the PHM, many countries have actually adopted such legislation. As a result, drug companies made 62 billion USD in profit last year. They oppose this situation and propose a vision of equity, ecologically-sustainable development and peace. The PHM recently established an International People's Health University.

The final presentation was given by Mr. Dave McCoy from Global Health Watch (GHW) and looked specifically at how to mobilize the global public health community around the basic issues of health. Mr. McCoy emphasized the fact that the health care crisis is not driven by diseases, but by governments. Resources are available but do not reach those who need them most. This has resulted, for example, in a reduction in life expectancy in some countries, especially on the African continent. Even though it has been demonstrated that it takes only 30 USD per capita on a yearly basis to provide adequate health care to all, too many countries struggle to make ends meet. In a country like Ethiopia, even 100% of its GDP would not cover all their health care needs. In short, the biggest global 'epidemic' is poverty. At the same time, tax evasion allowed the most fortunate to save 350 billion USD last year. The system in which we live facilitates the accumulation of wealth and corruption to the detriment of more important issues such as health care. Even more worrying is that no action seems to be taken. The global health crisis is therefore one of misdistribution of wealth. The role of GHW is to report on the global health crisis and to hold accountable those who are responsible for improving health (governments, corporations, international health agencies). Since access to health affects everyone, it is not just an individual government, but a global problem; hence the international health system needs to be readjusted. Mr. McCoy's final remarks were addressed to the WHO, which needs to increase its influence and to improve its organization so that it will be able to face the great challenges of today and in the future.

A quote from Rudolph Virchow, given by Mr. McCoy during his presentation, summarizes well the issues discussed during this symposium: "Politics is nothing more than medication on a larger scale". The ones affected most by the access to health care, the patients themselves, need to have their voice heard, and this will not happen unless governments focus their main interests towards the people rather than profit driven companies and NGOs involved in health care can work independently, in a competent manner, with the sole objective of making sure that decent health care is provided to the ones who most need it".

"The illnesses of invisible people usually stay invisible." With all the technological progress and the advances made by global health alliances, can this still be the reality? Indeed, 18 million people are suffering from Chagas' disease and 500,000 new infections with visceral leishmaniasis (kala-azar) occur per year. Who can and will take action to solve this problem? New ways, based on solidarity, knowledge sharing, and the collaboration of trans-national partnerships and countries were presented in this symposium on the most neglected diseases.

Numerous neglected diseases primarily affect the marginalised citizens of the most impoverished nations. The speakers of this symposium focused on sleeping sickness (African trypanosomiasis), leishmaniasis and Chagas' disease (American trypanosomiasis), which infect millions of people and are frequently fatal if left untreated.

Several problems in dealing with neglected diseases were raised. The current diagnostics and drugs are inadequate and often inaccessible due to their cost, ineffectiveness and lack of availability. New technologies for diagnosis and can be too difficult and complex to use in rural areas. Another problem is posed by the development of the disease itself, when chronic infections are more difficult to detect than an acute infection. This is the case for Chagas' disease, as described by Dr. François Chappuis from the Travel and Migration Medicine Unit at Geneva University Hospital in Switzerland. Drugs available today still pose problems such as toxicity, pain during delivery, follow-up difficulty, inadaptability to patients' needs (such as a lack of paediatric formulation), as well as compliance problems. Apart from the challenge of producing satisfactory drugs, these also have to be distributed effectively.

The following points were suggested to address these problems:

Development of generic drugs available at preferential prices

Production of safer drugs

Region-specific clinical trials

Simplified, sensitive and rapid diagnostic methods, favouring diagnosis on site

Instrument-free diagnosis if possible

Overcoming logistic nursing and mental barriers, such as the "nursing" barrier (reluctance to administer new treatment)

More practical screening approach

Promotion of combination drugs

Stronger transfer of technology into the developing world by facilitating the translation of promising platform technologies into global health products

Stronger capacity building effort for local research and development

Proper and wider distribution of medications by designing effective local strategies and networks to ensure access

According to Dr. Bernard Pécoul, Executive Director of the Drugs for Neglected Diseases initiative, neglected diseases fall outside the realm of the world pharmaceutical market because most of the afflicted are very poor, live in remote areas and often have no or limited political influence. He stated that a market-driven model would not be able to solve this problem, but that a new strategy needed to be developed.

The model proposed and established by the presenters is the public-private partnership (PPP), which comprises a network of private foundations and companies, research and academic institutions, governmental bodies and non-governmental organisations working towards the same goal in a collaborative, cooperative and non-competitive manner. Each panel member represented a particular PPP, namely the Institute of OneWorld Health (iOWH), the Drugs for Neglected Diseases initiative (DNDi), and the Foundation for Innovative New Diagnostics (FIND). Each of these PPPs addresses one or more of the most neglected diseases within their portfolio of projects.

In conclusion, the speakers remained optimistic despite the challenges in accomplishing the goals of treating the most neglected diseases. To overcome these challenges, the speakers emphasised the necessity of sharing knowledge and expertise by profiting from research previously carried out in pharmaceutical companies, such as Eisai in Japan on Chagas' disease. However, certain proven treatments in one country may not be entirely applicable to another region of the world. As an example, Dr. Pécoul presented encouraging results obtained from studies on combination drugs against leishmaniasis drugs to provide a shorter treatment regime in India, which could not be directly transferred to Africa.

Showing a hopeful outlook for the future, Dr. Jean Jannin, co-chair of this symposium, anticipates that access to health care will be facilitated by new agreements due to be signed between PPPs and the pharmaceutical industry in the near future. Agreements will also be arranged to address the issues of production and distribution. In sum, the speakers expressed the necessity of firm commitments and the duty to use the best science to provide the best tools in the fight against neglected diseases.